Provider Demographics
NPI:1558978452
Name:INDEPTH THERAPY, LLC
Entity Type:Organization
Organization Name:INDEPTH THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETHANY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANKENHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-232-2303
Mailing Address - Street 1:1008 DEPOT HILL RD # 201
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-6723
Mailing Address - Country:US
Mailing Address - Phone:720-232-2303
Mailing Address - Fax:
Practice Address - Street 1:3307 S COLLEGE AVE UNIT 217
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4196
Practice Address - Country:US
Practice Address - Phone:720-538-4357
Practice Address - Fax:720-358-0846
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDEPTH THERAPY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-25
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO59112557Medicaid